Will Insurance Cover Addiction if it’s Not a Disease?

However, insurers already pay for many conditions that are not diseases. For instance, broken bones, pregnancies, and the repair of congenital defects are not normally called diseases, but these conditions are covered by most insurance plans. The term that is relevant to an insurance company is “medical necessity.” The insurer does not care whether your cigarette smoking is a disease. If your stopping smoking is considered medically necessary, then the insurer will likely cover treatment to stop smoking, depending on the limitations and exclusions of your policy. You might be interested in reviewing just what is covered and excluded in your policy.

Some additional examples may clarify the issue of what insurance plans pay for when trying to answer the question: will insurance cover addiction if it’s not a disease? Many insurance plans cover mental health treatment. Suppose that you get in a bad auto accident. Suppose you keep having nightmares about the accident, and keep feeling more depressed. The insurer does not label your reaction a disease, but it may cover some psychotherapy sessions to help you overcome your understandable reaction to this stressful event.

On the other hand, suppose you have an infected tooth. Perhaps no health plan includes coverage for dental problems. Dental insurance is a separate policy. An infected tooth would fit most definitions of a “disease” but your health plan does not cover it. If you do not have dental insurance, you will need to pay for your dental work on your own. Ironically, if you do nothing for your tooth, and the infection spreads to another part of your body (perhaps your throat), your health insurance will then pay for treatment for your throat.

Similarly, drinking problems may not covered by your insurance. But if drinking leads to needing a liver transplant (a procedure that can cost hundreds of thousands of dollars), the transplant may be covered. Clearly, it is would save money to treat problems early, rather than treating their big consequences later. However, the financial incentives that exist in our current health care system may make it more cost-effective for insurance companies to avoid spending money on preventative care.

To summarize, then, whether a condition is covered is not based on whether it is a disease, but on whether it is included in the policy. The discussion we need to have is not about what is a disease, but about what health insurance should cover. A major advantage of a national health system is that coverage can be based on helping the population as a whole, and preventing problems rather than waiting for them to develop into costly problems later.

Ideally, whether we have a national health care or health insurance system, or just private insurance, it would help people make better choices if there were financial incentives for better behavior. As our technology improves we are likely to be able to determine rather precisely who smokes, drinks to excess, or uses other substances, just as easily as we are now able to determine who is overweight. It could improve health behavior substantially if people with good health habits paid less for health coverage.

Regardless of whether there are ever incentives for more healthy behavior, the idea that we need to call addictions diseases, in order to have health coverage for them, is incorrect. Insurance covers what it covers. We could decide to require that health insurance cover addiction treatment. Whether it is a good idea to require coverage for outpatient addiction treatment, or alcohol and drug rehab, is a separate discussion. But such coverage can simply be mandated by law whenever we choose.